Chaar and Gersin. J Obes Weight-Loss Medic 2015, 1:1 Journal of Obesity and Weight-loss Medication Review Article: Open Access Management of Immediate Complications Following Bariatric : Clinical Pearls for the Clinician Managing Bariatric Patients Maher El Chaar1* and Keith Gersin2

1School of Medicine, Temple University, St Luke’s University Hospital and Health Network, USA 2Chief Bariatric Surgery, Carolinas Medical Center, University of North Carolina, USA

*Corresponding author: Maher El Chaar, Clinical Associate Professor, School of Medicine, Temple University, St Luke’s University Hospital and Health Network, Co-Medical Director of Bariatric Surgery, Allentown, Pennsylvania, USA, E-mail: [email protected]

reflux disease, strictures, stenosis, weight regain and nutritional Abstract deficiencies. Although venous thromboembolic diseases and Bariatric surgery is the only effective long term treatment of morbid cardiac complications are not unique to weight loss surgery, they obesity. With the establishment of an accreditation process for may occur with greater frequency in the morbidly obese and are bariatric centers and the development of laparoscopic approaches to bariatric surgery, in addition to fellowship training, bariatric therefore included here [3]. In this review article we will focus on surgery became a role model for other surgical specialties in the immediate complications occurring after bariatric surgery and terms of efficacy and safety. Bariatric surgery has now a long track provide general guidelines as to the work-up and management of record of safety and a very low morbidity and mortality rates. In those complications. addition, the number of bariatric procedures being performed is increasing dramatically. Health care providers caring for bariatric Gastrointestinal Leakage patients will encounter on occasions certain complications specific to bariatric patients in the immediate postoperative period. The Gastrointestinal (GI) leakage is one of the most devastating objective of this review is to illustrate some of the immediate complications that can be encountered following bariatric surgery. postoperative complications following bariatric surgery to provide The possible sites of leakage are primarily from staple lines however general guidelines for a timely diagnosis and management of postoperative patients. These bariatric specific complications leaks can result from any anastomosis whether stapled, hand sewn include gastrointestinal leakage, gastrointestinal bleeding and or a combination of the two (Figure 1). In addition, missed serosal small . We will also discuss the diagnosis of injuries or enterotomies at the time of surgery are another likely postoperative thromboembolic and cardiac diseases in bariatric source. GI leakage usually occurs in the immediate postoperative patients. period but rarely may present several weeks following surgery and

Introduction Bariatric surgery is the only effective and proven long-term solution for the treatment for morbid obesity [1]. The number of patients undergoing bariatric surgery has increased dramatically in the past two decades due in part to the adoption of laparoscopic techniques [2]. It is imperative that clinicians caring for post- operative bariatric patients have a clear understanding and high index of suspicion for the potential complications that may arise following weight loss surgery. Failure to quickly and correctly diagnose these complications may lead to devastating outcomes, including death. Post-operative bariatric complications may be arbitrarily grouped into those occurring immediately following surgery (within the first 24-72 hours following surgery) and those occurring later (months to years). Immediate complications related to the surgical technique itself and occurring immediate after surgery include gastrointestinal leakage, bleeding, small bowel obstructions (intra-luminal or extra- luminal in origin) venous thromboembolic disease and cardiac Figure 1: UGI demonstrating a leak from the gastrojejunostomy anastomosis 1 day following a Laparoscopic Roux-en-Y-Gastric Bypass. Patient signs and events. Complications occurring later include hernias (internal symptoms include fever, tachycardia and abodominal pain. and incisional), symptomatic cholelithiasis, gastroesophageal

Citation: Chaar ME, Gersin K (2015) Management of Immediate Complications Following Bariatric Surgery: Clinical Pearls for the Clinician Managing Bariatric Patients. J Obes Weight-Loss Medic 1:003 ClinMed Received: March 01, 2015: Accepted: March 13, 2015: Published: March 16, 2015 International Library Copyright: © 2015 Chaar ME. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. usually results in increased morbidity and mortality. The incidence of GI leakage following gastric bypass surgery ranges between 1% and 5% with rates following revisional bariatric surgery even higher. [5- 7]. The incidence of GI leakage following sleeve gastrectomy ranges from 1.2% to 2.7% usually resulting from failure of the gastric sleeve staple line [8]. The differences in leakage rates between open and laparoscopic techniques remain controversial. Some authors have suggested that the leakage rates after laparoscopic roux-en-y-gastric bypass (LRYGB) are higher than when performed in an open fashion possibly due to surgeon experience and learning curve [9]. DeMaria et al. demonstrated a reduction in leakage rates from 6.8% to 1.8% after performing their first 102 LRYGB cases [10]. When performed by experienced surgeons, Nguyen et al. found no difference in the rate of postoperative anastomotic leakage rates between open and laparoscopic groups [11]. The use of routine post-operative contrast studies to rule out GI leakage remains controversial. Selective imaging based upon the patient’s clinical situation is acceptable [12]. Unstable patients with a suspicion of GI leakage should be explored immediately without the Figure 2: CT scan demonstrating hemoperitoneum 1 day following a need of any additional testing or radiographic studies. Two commonly Laparoscopic Roux-en-Y-Gastric Bypass (LRYGB). The patient developed abdominal pressure, tachycardia and a drop in hemoglobin following LRYGB performed diagnostic procedures include upper gastrointestinal series (UGI) and computerized axial tomography (CT) scanning. The sensitivity of these modalities varies depending upon patient related postoperative period patients may be managed by endoscopic stent factors and the experience of the interpreting radiologist. Limitations placement combined with laparoscopic or percutaneous drainage of of UGI series involve the inability to visualize all potential sources of abdominal collections [15,16]. Gastric outlet obstruction secondary GI leaks and therefore CT scanning is more sensitive in this regard. A to a leak and subsequent stenosis may require a revision to a roux- recent retrospective analysis of prospectively collected data on 3,018 en-y gastric bypass [17]. patients, demonstrated that leaks were detected in 17 of 56 patients (30%) when UGI series were used and in 28 of 50 patients (56%) In stable patients with a controlled leak, non-operative when CT scans were used [6]. Another advantage of abdominal management may be considered. These patients may have had a and pelvic CT scanning is the ability to reveal other intra-abdominal drain placed at the time of initial operation or subsequently via pathology that share similar clinical symptoms to GI leakage such interventional radiologic techniques. Patients who are managed as small bowel obstruction or intra-abdominal bleeding. A potential non-operatively are treated with antibiotic administration and limitation of CT scans is the inability to perform the procedure due parenteral nutrition and should be explored immediately if they fail to weight limitations or inability of patients to fit inside the scanners. to improve clinically, develop new symptoms or any signs of sepsis [18]. Endoscopic means to manage leaks following bariatric surgery Clinicians should not rely on radiographic studies alone in are preferentially performed in specialized large volume, tertiary determining which patients require operative interventions. A care centers under approved clinical trials and are not currently negative UGI or CT scan does not rule out the presence of GI leakage considered standards of care. ad in the appropriate clinical setting in the presence of signs and symptoms suggestive of GI leakage, a diagnostic or Gastrointestinal Bleeding laparotomy should be performed [9]. Patients with GI leakage may The rate of gastrointestinal bleeding (GIB) following bariatric present with one or more of the following signs and symptoms: surgery varies in the literature between 1 and 4% [5]. GIB usually fever, tachycardia, tachypnea, hypoxia, oliguria, abdominal, back or arises from staple lines, however may also be the result of injury to shoulder pain, feeling of impending doom and hypotension. intra-abdominal organs including the liver and spleen. A potential Basic surgical tenants should be followed to appropriately manage mechanism of staple line bleeding is the penetration of the mucosa by these patients requiring exploration. Exploration can be performed the stapler or the transaction of a vessel traversing the serosal layer of laparoscopically or in an open fashion. Laparoscopic exploration the stomach or small bowel [19]. may be technically challenging even for experienced laparoscopic Familiarity with the presentation of GIB following bariatric surgery surgeons because of bowel distension and acute inflammation is a necessity for those caring for these patients. GIB following bariatric leading to adhesions and ablation of tissue planes. At the time of surgery can be either intra-luminal, intra-abdominal (Figure 2) or exploration, all staple lines in addition the gastrojejunostomy both. In patients with signs and symptoms of increased abdominal (GJ) and jejunojejunostomy (JJ) anastomosis should be carefully pressure, shoulder pain, tachycardia, and decreased urine output, intra- inspected to help localize the site of leak. Gentle, blunt dissection abdominal GIB should be considered in addition to consideration of can minimize serosal injuries or enterotomies to the gastric pouch a gastric leak. Furthermore, patients with intra-luminal bleeding may or the roux limb secondary to the severe inflammatory reaction. An present with hematemesis when the bleeding originates from the intra-operative endoscopy can be very useful in localizing the site of gastrojejunostomy anastomosis. Signs of bowel obstruction may also leak. When a leak is identified, suture repair may be attempted and/or be present if the intra-luminal bleeding and subsequent clot formation omental patching if possible to cover the site of leakage. Abdominal obstructs the bowel at the jejuno-jejunostomy. The use of laboratory washout and wide drainage is also recommended [13]. If the site of studies may help confirm the presence of a GIB, however a normal leakage is not identified, abdominal washout and wide drainage is hemoglobin and hematocrit obtained shortly after surgery may not be recommended. At the conclusion of exploration, surgeons should reliable or reflective of acute post-surgical bleeding. A simple history consider the placement of a gastrostomy tube for decompression and can also help localize the site of bleeding in bariatric patients without feeding when warranted. the need of invasive diagnostic tests or imaging studies. For example, Staple line disruption and leakage after performance of a sleeve the site of bleeding in a patient presenting with hematemesis is more gastrectomy can develop in the immediate postoperative period or likely the staple line of the gastric pouch of the gastrojejunostomy several days later. In the immediate postoperative period, patients anastomosis whereas a patient presenting with blood per rectum is with leakage following sleeve gastrectomy should be explored, drained most likely bleeding from the newly formed jejenujejunostomy or the and the site of leakage identified and suture repaired [14]. In the later gastric remnant staple line [19].

Chaar and Gersin. J Obes Weight-Loss Medic 2015, 1:1 • Page 2 of 6 •

Figure 4: CT scan demonstrating dilated Roux limb secondary to an Figure 3: CT scan demonstrating dilated common channel and Roux limb obstruction of the JJ. This patient developed abdominal pain, nausea and following a Laparoscopic Roux-en-Y-Gastric Bypass. This patient presented non-bilious vomiting two days following the Laparoscopic Roux-en-Y-Gastric with abdominal pain and bilious vomiting. Bypass.

The management of post-operative GIB in bariatric patients the definition of “early” and “late” obstructions [25], there is no clear may be different than that of general surgery patients [20]. Bariatric consensus. Bariatric patients presenting with SBO in the immediate patients presenting with post-operative GIB, are best managed post-operative period usually report abdominal discomfort, bloating, in the operating room. Intubation is recommended to secure the nausea and vomiting. This usually results, in the immediate post- airway, help prevent aspiration and quickly convert to operative operative period, from technical issues with the construction of the interventions if required. The use of bedside, therapeutic endoscopy JJ, trocar site hernias or bleeding with intra-luminal blood clots. is to be discouraged in this patient population. Internal hernias can also result in SBO but they usually present Management of unstable patients with GIB includes the placement later and those will be discussed in other chapters [26,27]. Bilious of large bore intravenous lines and fluid and blood resuscitation. vomiting usually indicates obstruction distally in the common Intra-operative endoscopy is a useful adjunct, both diagnostically channel (Figure 3) while non-bilious vomiting is more indicative of and therapeutically. In addition in helping localize bleeding, many a proximal obstruction (Figure 4). These patients may be tachycardic endoscopic modalities (clip application, epinephrine injection, and hypoxic and therefore gastrointestinal leakage and bleeding must electrocautery) can successfully control GIB and obviate the need also be considered. for surgical intervention. Intra-luminal clots should be evacuated Diagnosis of SBO should be confirmed in a timely fashion to to allow endoscopic visualization and treatment and to help prevent prevent bowel necrosis or staple line breakdown and leakage. Physical the development of gastrointestinal obstruction from future clot examination may be unreliable as abdominal distension is difficult to migration. Surgical exploration, (either open or laparoscopic), may assess in the morbidly obese patients [28,29]. CT scanning is usually be indicated when the source of bleeding cannot be identified. At the performed when SBO is suspected and can frequently demonstrate time of exploration, intra-luminal or intra-abdominal clots should be the area of obstruction. Even with a negative CT scan, surgeons evacuated and the staple lines over sewn [19,21,22]. The additional should have a low threshold for performing a diagnostic laparoscopy need for placement of gastrostomy tubes for decompression or on those patients when there is a high index of suspicion of SBO to feeding remains controversial. prevent bowel necrosis. The management of GIB in stable patients may be resuscitative The management of the different causes of immediate post- only. In a recent report, 450 consecutive patients who underwent operative SBO will be discussed separately. LRYGB over a 30-month period at the Cleveland Clinic Florida were retrospectively reviewed. Twenty patients (4.4%) developed an acute First, SBO resulting from herniation thru trocar sites is managed postoperative bleed and among those only three patients (15%) were like in any general surgery patients. The herniated bowel should unstable and required an operation. The hemodynamically stable be reduced and the defect closed. The presence of bowel necrosis patients were managed successfully with non-procedural measures following SBO necessitates bowel resection and reanastomosis. In the including 15 patients (75%) who required blood transfusions [23]. past, it was suggested that closure of any trocar larger than 5mm is Stable patients who subsequently manifest ongoing bleeding or necessary to prevent herniation. Today, with the advent of the new become unstable should be intubated and treated endoscopically, dilating trocars, there is no need for fascial closure of any trocar site surgically or a combination of both. that is 12 mm or less. However, many surgeons continue to close any trocar site that is larger than 5 mm. It’s important to note that Small Bowel Obstruction even though it’s extremely difficult to make the diagnosis of trocar site herniation by physical exam because of the bariatric patient body Small bowel obstruction (SBO) following bariatric surgery can habitus, the diagnosis is easily made using CT scanning [30-32]. lead to staple line breakdown and leakage, bowel necrosis and even death. The incidence of small bowel obstruction ranges from 1.5% to Second, SBO resulting from gastrointestinal hemorrhage and the 11% following LRYGB [24]. SBO can result from incisional hernias, presence of intraluminal blood clot should follow the same guidelines internal hernias, adhesions, cicatrisation of the roux-limb at the level for managing bariatric patients with GI hemorrhage. As previously of the mesocolon, intra-luminal blood clots, intussusception of the mentioned, the bleeding site should be controlled and the intra- roux-limb and technical issues associated with the construction of the luminal clot evacuated thru an enterotomy or gastrotomy depending jejunojejunostomy (JJ) [24,25]. on the site of bleeding to relieve the SBO [19,22]. SBO following bariatric surgery can be divided into early and Third, obstruction at the JJ can result from narrowing of the late obstruction. While some authors have attempted to standardize anastomosis, edema, hematoma or acute angulation (Figure 3). In

Chaar and Gersin. J Obes Weight-Loss Medic 2015, 1:1 • Page 3 of 6 • addition, bleeding at the JJ can also result in an intraluminal blood (AACE), the Obesity Society (TOS) and the ASMBS published clot and a secondary SBO as previously mentioned. Obstruction at a set of recommendations regarding their use. These societies the JJ usually presents early but can also be seen within 7 to 19 days recommend that bariatric patients at risk for, or with a history of, following the index operation [29]. Adherence to sound surgical deep venous (DVT) or cor pulmonale should undergo an principles and achieving hemostasis at the time of the creation of JJ appropriate diagnostic evaluation for DVT. In addition, investigators can prevent bleeding, edema or the formation of hematoma. Acute recommended a prophylactic vena caval filter for patients with a angulation at the JJ can be prevented by the placement of one or two history of prior PE, immobility, BMI>55, prior ileo-femoral DVT, anti-obstruction stitches (Brolin Stitch) to approximate both limbs of evidence of venous stasis, known hypercoagulable state, pulmonary the JJ anastomosis [33]. To prevent stenosis at the JJ, which usually hypertension, obesity hypoventilation increased right-sided heart results from closing the common enterotomy with a linear stapling pressures [43,44]. Other studies, however, have shown a high device, some authors have suggested suture closure of the enterotomy. incidence of device related complications [4]. Additionally data from Another suggestion is the use of a new technique called “bidirectional the Bariatric Outcomes Longitudinal Database (BOLD) showed that firing” or “triple-stapling technique”. Using this technique, a surgeon IVC filter resulted in higher incidence of VTE [45]. The latest AMBS fires two separate cartridges in opposite directions to create the position statement on IVC filter placement recommend against the anastomosis and then the common enterotomy is closed with a routine use of IVC filters. However, IVC filter placement can be third linear firing [34-36]. The management of SBO secondary to considered in addition to mechanical and chemical prophylaxis in obstruction at the JJ usually requires reexploration and revision of selected high risk patients [42]. the JJ anastomosis. Cardiovascular Disease Another uncommon reason for SBO following LRYGB is the Roux-en-O configuration in which the inappropriate identification Obesity is a well-known independent risk factor for cardiovascular of the roux limb and the bilio-pancreatic limb can result in the events. One reason bariatric patients with cardiac risk factors seek connection of the bilio-pancreatic limb to the gastric pouch. If the bariatric surgery is to decrease their overall long-term cardiovascular improper connection is not identified intraoperatively and addressed, risk. Patients undergoing bariatric demonstrated a reduction in it may result in symptoms and signs of small bowel obstruction in cardiovascular events and deaths [46-49]. To determine the safety the postoperative period. Those patients usually present in the late and efficacy of bariatric surgery in obese patients with documented postoperative period [37]. coronary artery disease (CAD), the rates of in-hospital cardiovascular complications and mortality of 52 patients with clinical CAD were Venous Thrombo-Embolic Disease compared with those of 507 patients without CAD. The rate of Venous thrombo-embolic disease (VTE) is a complication that cardiovascular complications was 5.8% for patients with documented may present in the early post-operative period following bariatric CAD and 1.4% for patients without CAD (p=0.06). The authors surgery. The incidence has been reported to be 1% with no statistical concluded that bariatric surgery could be safely performed in differences observed between open RYGB, LRYGB and laparoscopic patients with documented CAD [50]. The Longitudinal Assessment adjustable gastric banding (LAGB) procedures [38]. The diagnosis of Bariatric Surgery (LABS) consortium performed a prospective, and management of VTE following bariatric surgery is similar to any multicenter, observational study of 30-day outcomes in consecutive surgical procedure and not unique to weight loss surgery. It is worth patients undergoing first-time bariatric procedures at 10 clinical sites noting however, that the differential diagnosis of a patient presenting in the United States between 2005 and 2007. The 30-day mortality with hypoxia, shortness of breath, tachycardia and impending sense rate among the 4776 patients included in the study was 0.3% [38]. of doom following bariatric surgery should include, in addition to Morino M et al. studied 13,871 patients who underwent bariatric pulmonary embolus (PE), gastrointestinal leakage and bleeding. surgery between January 1996 and January 2006 and reported sixty- CT angiography (CTA) has become the diagnostic test of choice for day mortality rate of 0.25%, 17.6% of which were cardiac the deaths the evaluation of patients with suspected PE unless the patient has [51]. a contraindication to receiving intravenous contrast or exceeds the Given the low mortality of patients with CAD following bariatric weight limit of the scanner [39,40]. surgery and the clear benefit of bariatric surgery in reducing the The focus of VTE as relates to bariatric surgery patients, lies in its’ overall rate of cardiovascular events and deaths, it’s generally prevention. To date, there is no consensus or standard of care when it recommended to offer bariatric surgery for patients with CAD after a comes to VTE prophylaxis. Some clinicians prefer chemoprophylaxis, cardiac evaluation [50]. pneumatic compression devices or a combination of the two to aid According to the American College of Cardiology/American in the prevention of VTE [41]. The American Society for Metabolic Heart Association ACC/AHA 2009 guidelines, bariatric surgery and Bariatric Surgery (ASMBS) clinical issues committee published is an intermediate risk surgery and all patients with active cardiac a position statement in June 2007, regarding prophylactic measures disease should undergo noninvasive testing. For patients with no to reduce the risk of VTE in bariatric surgery patients. The position active cardiac disease, and given the fact that bariatric surgery is an statement was later revised in 2013. In its guidelines, obese patients intermediate risk surgery, the functional status of the patient should undergoing bariatric surgery were noted to be at moderate to high be assessed. Patients with good functional status and functional risk for VTE and therefore preventive measures in the peri-operative capacity greater or equal to 4 (Metabolic Equivalents) METs without period were recommended. The use of lower extremity sequential symptoms should proceed to surgery. However, it’s usually difficult compression devices and early ambulation were recommended and to assess functional capacity in bariatric patients because of their deemed appropriate for all bariatric patients when clinically feasible. weight and limited activity and therefore risk stratification should be In addition, routine administration of chemoprophylaxis, when performed to determine the presence or absence of clinical risk factors, not contraindicated, was recommended in addition to mechanical which include diabetes mellitus, renal insufficiency, compensated prophylaxis, for all bariatric surgery patients but the choice, dosage or prior heart failure and ischemic heart disease. If the patient has and duration of anticoagulation administration remain controversial. no clinical risk factors then he or she can proceed to surgery. In the Also, in low risk patients the use of mechanical prophylaxis alone presence of 1 or more risk factors it’s recommended by the AHA to was shown to result in low risk of VTE (<0.45).Individual practices proceed with non-invasive testing or surgery with heart rate control were also encouraged to develop and adhere to protocols for the with beta- blockers [52]. prevention of VTE [42]. Conclusion The use of inferior vena cava (IVC) filters pre-operatively to prevent post-operative PE also remains controversial. In 2008 Clinicians caring for bariatric surgical patients need to have a clear and 2009, the American Association of Clinical Endocrinologists understanding as to the potential complications that may arise in

Chaar and Gersin. J Obes Weight-Loss Medic 2015, 1:1 • Page 4 of 6 • the immediate postoperative period. Although weight loss surgery 21. Steffen R (2003) Early gastrointestinal hemorrhage after laparoscopic gastric is safe with a low mortality, delay in the recognition of complications bypass. Obes Surg 13: 466. may lead to increased morbidity and mortality rates. Many of the 22. Nguyen NT, Rivers R, Wolfe BM (2003) Early gastrointestinal hemorrhage complications mentioned in this chapter present with similar signs after laparoscopic gastric bypass. Obes Surg 13: 62-65. and symptoms; therefore a heightened awareness as to the differential 23. Mehran A, Szomstein S, Zundel N, Rosenthal R (2003) Management of acute diagnosis is imperative. CT scanning is a useful adjunct in the bleeding after laparoscopic Roux-en-Y gastric bypass. Obes Surg 13: 842- diagnosis of many of these complications. Finally, prevention of these 847. complications is equally as important as prompt recognition and 24. Hwang RF, Swartz DE, Felix EL (2004) Causes of small bowel obstruction treatment. after laparoscopic gastric bypass. Surg Endosc 18: 1631-1635. 25. Nguyen NT, Huerta S, Gelfand D, Stevens CM, Jim J (2004) Bowel obstruction References after laparoscopic Roux-en-Y gastric bypass. Obes Surg 14: 190-196. 1. Picot J, Jones J, Colquitt JL, Gospodarevskaya E, Loveman E, et al. (2009) 26. Higa KD, Ho T, Boone KB (2003) Internal hernias after laparoscopic Roux- The clinical effectiveness and cost-effectiveness of bariatric (weight loss) en-Y gastric bypass: incidence, treatment and prevention. Obes Surg 13: surgery for obesity: a systematic review and economic evaluation. Health 350-354. Technol Assess 13: 1-190, 215-357, iii-iv. 27. Garza E Jr, Kuhn J, Arnold D, Nicholson W, Reddy S, et al. (2004) Internal 2. Nguyen NT, Root J, Zainabadi K, Sabio A, Chalifoux S, et al. (2005) hernias after laparoscopic Roux-en-Y gastric bypass. Am J Surg 188: 796- Accelerated growth of bariatric surgery with the introduction of minimally 800. invasive surgery. Arch Surg 140: 1198-1202. 28. Gunabushanam G, Shankar S, Czerniach DR, Kelly JJ, Perugini RA (2009) 3. Poirier P, Alpert MA, Fleisher LA, Thompson PD, Sugerman HJ. et al. Small-bowel obstruction after laparoscopic Roux-en-Y gastric bypass (2009) Cardiovascular Evaluation and Management of Severely Obese surgery. J Comput Assist Tomogr 33: 369-375. Patients Undergoing Surgery: A Science Advisory From the American Heart Association. Circulation 120: 86-95. 29. Koppman JS, Li C, Gandsas A (2008) Small bowel obstruction after laparoscopic Roux-en-Y gastric bypass: a review of 9,527 patients. J Am Coll 4. Birkmeyer NJ, Share D, Baser O, Carlin AM, Finks JF, et al. (2010) Surg 206: 571-584. Preoperative placement of inferior vena cava filters and outcomes after gastric bypass surgery. Ann Surg 252: 313-318. 30. Felsher J, Brodsky J, Brody F (2003) Small bowel obstruction after laparoscopic Roux-en-Y gastric bypass. Surgery 134: 501-505. 5. Podnos YD, Jimenez JC, Wilson SE, Stevens CM, Nguyen NT (2003) Complications after laparoscopic gastric bypass: a review of 3464 cases. 31. Bhoyrul S, Payne J, Steffes B, Swanstrom L, Way LW (2000) A randomized Arch Surg 138: 957-961. prospective study of radially expanding trocars in laparoscopic surgery. J Gastrointest Surg 4: 392-397. 6. Gonzalez R, Sarr MG, Smith CD, Baghai M, Kendrick M, et al. (2007) Diagnosis and contemporary management of anastomotic leaks after gastric 32. Chiong E, Hegarty PK, Davis JW, Kamat AM, Pisters LL, et al. (2010) Port- bypass for obesity. J Am Coll Surg 204: 47-55. site hernias occurring after the use of bladeless radially expanding trocars. Urology 75: 574-580. 7. Fernandez AZ Jr, DeMaria EJ, Tichansky DS, Kellum JM, Wolfe LG, et al. (2004) Experience with over 3,000 open and laparoscopic bariatric 33. Brolin RE (1995) The antiobstruction stitch in stapled Roux-en-Y procedures: multivariate analysis of factors related to leak and resultant enteroenterostomy. Am J Surg 169: 355-357. mortality. Surg Endosc 18: 193-197. 34. Frantzides CT, Zeni TM, Madan AK, Zografakis JG, Moore RE, et al. (2006) 8. Brethauer SA, Hammel JP, Schauer PR (2009) Systematic review of sleeve Laparoscopic Roux-en-Y Gastric bypass utilizing the triple stapling technique. gastrectomy as staging and primary bariatric procedure. Surg Obes Relat JSLS 10: 176-179. Dis 5: 469-475. 35. Madan AK, Frantzides CT (2003) Triple-stapling technique for 9. Lee S, Carmody B, Wolfe L, Demaria E, Kellum JM, et al. (2007) Effect of jejunojejunostomy in laparoscopic gastric bypass. Arch Surg 138: 1029-1032. location and speed of diagnosis on anastomotic leak outcomes in 3828 36. Ahmad A, Cho K, Brathwaite C (2004) A technique of enteroenterostomy gastric bypass cases. J Gastrointest Surg 11: 708-713. to prevent alimentary limb obstruction in laparoscopic Roux-en-Y gastric 10. DeMaria EJ, Sugerman HJ, Kellum JM, Meador JG, Wolfe LG (2002) Results bypass. J Am Coll Surg 198: 159-162. of 281 consecutive total laparoscopic Roux-en-Y gastric bypasses to treat 37. Sherman V, Dan AG, Lord JM, Chand B, Schauer PR (2009) Complications morbid obesity. Ann Surg 235: 640-645. of gastric bypass: avoiding the Roux-en-O configuration. Obes Surg 19: 11. Nguyen NT, Goldman C, Rosenquist CJ, Arango A, Cole CJ, et al. (2001) 1190-1194. Laparoscopic versus open gastric bypass: a randomized study of outcomes, 38. Longitudinal Assessment of Bariatric Surgery (LABS) Consortium, Flum quality of life, and costs. Ann Surg 234: 279-289. DR, Belle SH, King WC, Wahed AS, et al. (2009) Perioperative safety in the 12. Lee SD, Khouzam MN, Kellum JM, DeMaria EJ, Meador JG, et al. (2007) longitudinal assessment of bariatric surgery. N Engl J Med 361: 445-454. Selective, versus routine, upper gastrointestinal series leads to equal 39. Nikolaou K, Thieme S, Sommer W, Johnson T, Reiser MF (2010) Diagnosing morbidity and reduced hospital stay in laparoscopic gastric bypass patients. pulmonary embolism: new computed tomography applications. J Thorac Surg Obes Relat Dis 3: 413-416. Imaging 25: 151-160.

13. Yurcisin BM, DeMaria EJ (2009) Management of leak in the bariatric gastric 40. Hartmann IJ, Wittenberg R, Schaefer-Prokop C (2010) Imaging of acute bypass patient: reoperate, drain and feed distally. J Gastrointest Surg 13: pulmonary embolism using multi-detector CT angiography: an update on 1564-1566. imaging technique and interpretation. Eur J Radiol 74: 40-49.

14. Csendes A, Braghetto I, León P, Burgos AM (2010) Management of leaks 41. Clements RH, Yellumahanthi K, Ballem N, Wesley M, Bland KI (2009) after laparoscopic sleeve gastrectomy in patients with obesity. J Gastrointest Pharmacologic prophylaxis against venous thromboembolic complications is Surg 14: 1343-1348. not mandatory for all laparoscopic Roux-en-Y gastric bypass procedures. J 15. Nguyen NT, Nguyen XM, Dholakia C (2010) The use of endoscopic stent in Am Coll Surg 208: 917-921. management of leaks after sleeve gastrectomy. Obes Surg 20: 1289-1292. 42. American Society for Metabolic and Bariatric Surgery Clinical Issues 16. Tan JT, Kariyawasam S, Wijeratne T, Chandraratna HS (2010) Diagnosis Committee (2013) ASMBS updated position statement on prophylactic and management of gastric leaks after laparoscopic sleeve gastrectomy for measures to reduce the risk of venous thromboembolism in bariatric surgery morbid obesity. Obes Surg 20: 403-409. patients. Surg Obes Relat Dis 9: 493-497.

17. Bellorin O, Lieb J, Szomstein S, Rosenthal RJ (2010) Laparoscopic 43. Mechanick JI, Kushner RF, Sugerman HJ, Gonzalez-Campoy JM, Collazo- conversion of sleeve gastrectomy to Roux-en-Y gastric bypass for acute Clavell ML, et al. (2008) American Association of Clinical Endocrinologists, gastric outlet obstruction after laparoscopic sleeve gastrectomy for morbid The Obesity Society, and American Society for Metabolic & Bariatric Surgery obesity. Surg Obes Relat Dis 6: 566-568. Medical Guidelines for Clinical Practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Surg Obes 18. Csendes A, Burdiles P, Burgos AM, Maluenda F, Diaz JC (2005) Conservative Relat Dis 4: S109-184. management of anastomotic leaks after 557 open gastric bypasses. Obes Surg 15: 1252-1256. 44. Mechanick JI, Kushner RF, Sugerman HJ, Gonzalez-Campoy JM, Collazo- Clavell ML, et al. (2009) American Association of Clinical Endocrinologists, 19. Nguyen NT, Longoria M, Chalifoux S, Wilson SE (2004) Gastrointestinal The Obesity Society, and American Society for Metabolic & Bariatric Surgery hemorrhage after laparoscopic gastric bypass. Obes Surg 14: 1308-1312. medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Obesity 20. Monkhouse SJ, Morgan JD, Norton SA (2009) Complications of bariatric (Silver Spring) 17 Suppl 1:S1-70. surgery: presentation and emergency management--a review. Ann R Coll Surg Engl 91: 280-286. 45. Li W1, Gorecki P, Semaan E, Briggs W, Tortolani AJ, et al. (2012) Concurrent

Chaar and Gersin. J Obes Weight-Loss Medic 2015, 1:1 • Page 5 of 6 • prophylactic placement of inferior vena cava filter in gastric bypass and 49. Jazet IM, de Groot GH, Tuijnebreyer WE, Fogteloo AJ, Vandenbroucke JP, adjustable banding operations in the Bariatric Outcomes Longitudinal et al. (2007) Cardiovascular risk factors after bariatric surgery: Do patients Database. J Vasc Surg 55: 1690-1695. gain more than expected from their substantial weight loss? Eur J Intern Med 18: 39-43. 46. Sjöström L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, et al. (2004) Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric 50. Lopez-Jimenez F, Bhatia S, Collazo-Clavell ML, Sarr MG, Somers VK (2005) surgery. N Engl J Med 351: 2683-2693. Safety and efficacy of bariatric surgery in patients with coronary artery disease. Mayo Clin Proc 80: 1157-1162. 47. Batsis JA, Romero-Corral A, Collazo-Clavell ML, Sarr MG, Somers VK, et al. (2007) Effect of weight loss on predicted cardiovascular risk: change in 51. Morino M, Toppino M, Forestieri P, Angrisani L, Allaix ME, et al. (2007) cardiac risk after bariatric surgery. Obesity (Silver Spring) 15: 772-784. Mortality after bariatric surgery: analysis of 13,871 morbidly obese patients from a national registry. Ann Surg 246: 1002-1007. 48. Batsis JA, Sarr MG, Collazo-Clavell ML, Thomas RJ, Romero-Corral A, et al. (2008) Cardiovascular risk after bariatric surgery for obesity. Am J Cardiol 52. Fleischmann KE, Beckman JA, Buller CE, Calkins H, et al. (2009) 2009 102: 930-937. ACCF/AHA focused update on perioperative beta blockade. J Am Coll Cardiol 54: 2102-2128.

Chaar and Gersin. J Obes Weight-Loss Medic 2015, 1:1 • Page 6 of 6 •